Chapter 08: Growing Through Balance in Clinical and Research Activities

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Chapter 08: Growing Through Balance in Clinical and Research Activities

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In this chapter, Dr. Bruera talks about the challenges his faculty face balancing research efforts with substantial clinical responsibilities. He notes that developing research was essential to building the credibility of palliative care, but with few faculty, it was difficult to organize adequate time to conduct studies. Dr. Bruera explains a creative approach he took, establishing international partnerships to gather data. These studies then served as the foundation for two of the department's 3 RO-1 grants. Next, he explains the department's growth pattern, noting that as a 'fringe' department, he was never provided funds and resources in anticipation of growth. However, he notes, the department demonstrated it could sustain itself, which led to additional resources. Dr. Bruera then discusses strategies the department instituted so faculty, fellows, and staff could support each other in this stressful environment. He notes that his department is one of the most successful and research-productive in the country. He comments on Dr. Waun Ki Hong, Division head, as a fair leader. Dr. Bruera also sketches the egalitarian culture he has established in the department and shares his view that clinical work is an essential counterpart to conducting research in the field of palliative care.

Identifier

BrueraE_02_20180813_C08

Publication Date

8-13-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Leadership; On Leadership; The Researcher; Institutional Politics; MD Anderson Culture; On Research and Researchers; Professional Values, Ethics, Purpose; Philanthropy, Fundraising, Donations, Volunteers; Professional Practice; The Professional at Work; MD Anderson Culture; Working Environment; Collaborations; Multi-disciplinary Approaches

Transcript

Tacey A. Rosolowsi, PhD:

Can I ask you, how many people did you have involved in the department at that time, in different categories of roles?

Eduardo Bruera, MD:

At the very beginning four.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

It was only four.

Tacey A. Rosolowsi, PhD:

Tiny shop.

Eduardo Bruera, MD:

Yeah, and we were here all the time, because we were on call one out of every four days, one out of every four weekends, so we were working clinical hours in addition to research hours, a long time.

Tacey A. Rosolowsi, PhD:

So this is four faculty members?

Eduardo Bruera, MD:

Four faculty members.

Tacey A. Rosolowsi, PhD:

And who were the other folks involved?

Eduardo Bruera, MD:

The other folks, at that point were Donna Zhukovsky, Paul Walker, Mike Fisch [oral history interview], who later left to go to AIM healthcare, and me. There were four of us. That initial team was very, very busy and it was long hours, and for a while it looked quite hopeless.

Tacey A. Rosolowsi, PhD:

What did you mean, hopeless?

Eduardo Bruera, MD:

Because there was a lot of hard work, there was not a clear idea that resources might be coming, and that the institution might buy our product, but also that we would be able to do anything with our academic careers, that we would be able to get some publications and get promoted and so on.

Tacey A. Rosolowsi, PhD:

Right. Because you were just putting in the hours in the clinic at that point.

Eduardo Bruera, MD:

A lot of hours in the clinic and of course, what really gets you promoted are the papers, so getting that balance between the hours in the clinic and the papers, was always a big challenge.

Tacey A. Rosolowsi, PhD:

Now did you focus it down and kind of strategize, or how did you approach that clinical research balance? Did you kind of figure out papers that could come naturally out of the clinical work you were doing? How did you approach that question, to help support your colleagues?

Eduardo Bruera, MD:

Well at the very beginning, we went into real survival mode. We knew that we had to build the clinical practice to be able to then do the academic practice. Then we had very limited ability to do academic work because of the clinical demands.

Tacey A. Rosolowsi, PhD:

And that was one of the original mission areas that John Mendelsohn had wanted you to develop, I remember you telling me, is to build the research piece.

Eduardo Bruera, MD:

Yes. And so unless the clinical care, the patients are safe, then it gets hard to build the other part. So I was able to build some preliminary data and I did it in a way that was kind of unusual. I was not given a lot of establishment monies, and I had to use some of that to hire doctors to do clinical care. So some of my establishment package was used to pay some doctors, because I had no positions. Then, I did that preliminary data with international centers. I had built a little bit of a reputation when I was in Canada, as somebody who could get research done, and so I got people from Denmark, Australia, and some other centers in Canada, and we established an international kind of research group. I was able to send them a little bit of money. It wasn’t that much, but enough to help them collect data that we needed. We passed a couple of protocols through the IRB and we started collecting data. That data was very, very useful because that data was what allowed us to write our first R01s with the NIH, because we were doing a lot of clinical work. We did not have too many patients, but I was extremely lucky that --or fortunate and grateful-- that several international colleagues, we brought them here to Houston. We spent two days discussing clinical studies, specific clinical studies that they were going to do. They went back home and they basically got the studies, the data collected for us. So at a time when our clinical programs were not working very well, they were in a sense, they were trusting that at some point we were going to be okay, and they participated in the studies. That data was what we really used for two of our three R01s, of the three R01s I got, and I used that data as the pillar, the preliminary data was used for the application.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

So as we were growing clinically, I was continuously going after --we had saturated the clinical practice to the point of exceeding ourselves by one full position. Then I made the case, and we got one more, and then we got another more, and then we got another more, as the clinical. But of course each growth was very painful for us. It meant that first we had to grow the clinical activity to the point that would justify one more faculty position, then ask for the faculty position, then wait until the faculty position was hired. And at that point the burden came down a little bit and then that job started again. So, we were not one of the departments that were lucky enough to get upfront support. We knew that—and I knew that from every aspect of where I’ve been, it’s always very hard to grow a program that is not right in the main highway of what an institution does. So if an institution is in the area of heart care, like the Texas Heart Institute, you know that what will give you a lot of work, prestige and resources, is to be a cardiologist or a cardiothoracic surgeon. If you’re an ophthalmologist working there, or an internist, you are not in the mainstream. Of course palliative care is never in the mainstream, because there are no big palliative care hospitals. Actually, there is one in New York, but there’s almost none anywhere else. So, we knew that we were not going to ever be given resources in anticipation of growth. It was always going to have to be the opposite procedure. That is, you first grow, you show the growth, then you ask for the resources to cover. But of course, you’re always at the edge of burnout, because you’re having big demands. So what we did is we, every year consorted ourselves and said are we able to grow the business? Yes. Okay, how many positions do we ask for? One more or two more? That’s what we did, and we continuously started asking for that growth. As the decompression started to happen for weekends and vacation and so on, then writing became a little bit easier, because now we had more time. Even if it was weekend time, we had more time to allocate to the nonclinical part of the operation. And those grants that we obtained helped us, because then Dr. Hong and the rest of the institution saw that we could be independently funded. Regrettably, there are many things that we never got. So we never got development monies really. We never got a Moon Shot. We never got proposed by the institution to be separate, and so we knew that we were going to have to pay our own way into all this.

Tacey A. Rosolowsi, PhD:

Right. Now when you said you never got development monies, are you meaning that from the Development Office?

Eduardo Bruera, MD:

Yes, yes.

Tacey A. Rosolowsi, PhD:

Okay, so philanthropic dollars were not coming.

Eduardo Bruera, MD:

Yes. Yes.

Tacey A. Rosolowsi, PhD:

Which actually surprises me, that surprises me.

Eduardo Bruera, MD:

Well, yeah, it’s a list, that I don’t know how they’re going to do it now with Peter Pisters and Steve Hahn, but historically, it was a list of people who are designated by the senior leadership, to be in the list of recipients of arriving monies and therefore, the institution made a strategy for development.

Tacey A. Rosolowsi, PhD:

Right.

Eduardo Bruera, MD:

Our programs was not one of the ones that were high on that list, the same as we’re not high or low, we’re just not there.

Tacey A. Rosolowsi, PhD:

Right. I mean, as they draw up the institutional priorities and then they assigned based on that, right?

Eduardo Bruera, MD:

Yes, that’s right. The same happened with getting separate grants, and being one of the institutional grants for those. The same happened with the Moon Shots and being highlighted for that. So we knew that we had to basically pay our way into other academic activities, but we developed a strategy within our team, to support each other and to basically help each other be productive. We were, I think, fortunate in the sense that the team, the members that were arriving, were willing to put a little bit of time --because we didn’t have an awful lot of time-- but a little bit of time into writing, into doing papers. My job was to provide them with the infrastructure, to get the research nurses, the statisticians, the people who would make their life easy, so that our clinically busy faculty would not have to be running around trying to get money. The money was my job, and they got to work on the ideas and the projects, and write them and so on, and that helped us. Over the years, we have been one, I think by far, of the most productive academic teams in palliative care in the United States.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

The reason for that was not because we had particularly geniuses that were hired for hundreds of millions of dollars; we just had a group of people who, we were all mediocre, but we all got together and we pitched in together, and I think we managed to get those studies finished. So we managed to get some discoveries and to make some contributions. Then that is very nice because once people find --once a faculty member finds that their name is in the paper and that they made a contribution, that becomes addictive. Now they really want to do the second one and they really want to do the third one. The first one is horribly painful, the second is as painful, and third is probably a little bit easier, and once you got six or seven or eight papers, you say I can ride this bicycle, I can do this. Then more of them started taking the challenge of writing grants. Then we were able to move our first faculty to a tenure track position several years after that. The first one we were able to move was Sriram Yennu, who was working on fatigue.

Tacey A. Rosolowsi, PhD:

And the last name is spelled?

Eduardo Bruera, MD:

It’s Y-e-n-n-u. Sriram. He was one of our fellows that we hired. He was wonderful and very interesting in fatigue. Finally, we got for him, a mentor, American Cancer Society Scholarship, and so we went to Dr. Hong and said, we have this grant but it requires him to have a lot of protected time and we’re having a lot of patients. I would love to give him the time, but then we would need to hire a clinical position to cover for that. He looked at the numbers, he looked at us, and he said, “That’s fine, do it,” because Dr. Hong was not in this area, but he was an incredibly fair and data oriented leader. If he could see the papers, the publications, he could see the grants, and he could see the clinical encounters, then he would be fair in the allocation of resources, he would not be biased. That was an extraordinarily good thing for us to have. The second one was David Hui, who came and trained with me, from Canada, as a research fellow. David was able to get again, a scholarship, and also to get an R01 grant reasonably early, and we were able to then switch him to the tenured track, and so now we had a core team of three tenured track faculty, both of them and me. Then we were able to now keep more grants going and get more monies so that all the non-tenured track people were able to get some research done. We always operated as a cooperative effort, meaning by that, that we did not have any difference between the tenure or tenured track, and the non-tenure, with regards to for example, weekend call, holiday call and everything else. Everybody was pitching in the same way. The only difference is during the working hours, the tenured people were doing more research papers and the clinical people were seeing more patients. But we never found that it was important to establish this pyramidal thing in which the tenure people got all the time, all the money and then didn’t do call or did almost no clinical work. We felt, and I personally felt, that being clinically good was essential to the research work, particularly in our field. We don’t do any laboratory research, we don’t do any of those things of basic research and basically, even if you do that, I believe that you can be dangerous to patients and families if you don’t keep a good clinical practice. So we had to make sure that everybody practiced clinically, and so then it became easier, because now the team was larger and we had people working in different areas, and then we started getting advanced practice practitioners.

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Chapter 08: Growing Through Balance in Clinical and Research Activities

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